LETTERS TO THE EDITOR
|Year : 2022 | Volume
| Issue : 6 | Page : 785-787
A low-cost contraption for controlled talc poudrage for thoracoscopic pleurodesis
Nellai Krishnan, Vishesh Jain, Anjan Kumar Dhua
Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||22-Apr-2022|
|Date of Decision||15-May-2022|
|Date of Acceptance||30-Jul-2022|
|Date of Web Publication||11-Nov-2022|
Anjan Kumar Dhua
Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnan N, Jain V, Dhua AK. A low-cost contraption for controlled talc poudrage for thoracoscopic pleurodesis. J Indian Assoc Pediatr Surg 2022;27:785-7
|How to cite this URL:|
Krishnan N, Jain V, Dhua AK. A low-cost contraption for controlled talc poudrage for thoracoscopic pleurodesis. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2023 Nov 29];27:785-7. Available from: https://www.jiaps.com/text.asp?2022/27/6/785/360966
Talc pleurodesis is a specific form of chemical pleurodesis, which is indicated in cases of recurrent pleural effusion or pneumothorax, or persistent pneumothorax as a backup or salvage strategy in select cases, even in the pediatric age group. Sterilized talc can be administered either as talc slurry (via chest tube) or talc poudrage (via thoracoscopy). The latter technique has been found to be superior. However, the sterile talc that is factory packed with propellant in a ready-to-use form as an aerosol involves higher costs with a cost difference from the sterile talc packed in a standard vial to the tune of 40–50 USD. Hence, an innovative technique of talc poudrage was developed using a mucus extractor (a simple and cheap device used for aspiration and collection of samples from the oropharynx and airways) connected to a manual air insufflator device used during the rigid esophagoscopy procedures [Figure 1]a and [Figure 1]b.
|Figure 1: Equipment necessary for the low.cost contraption used for talc pleurodesis. (a) Mucus extractor. (b) Manual air insufflator used for rigid esophagoscopy. (c) After filling the contraption with sterile talc, squeezing the insufflator disperses the talc|
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Essentially, it consists of filling the chamber with an appropriate amount of talc (the commercially available vial contains two gms.) and closing the lid. Further, it must be ensured that the mucus extractor is free of moisture; else, it will result in clumping of the talc particles and failure of talc poudrage. The end, which is supposed to be connected to suction during aspiration of mucus, is connected to the manual air insufflator [Figure 1]c. The tube at the other end (containing an end-on opening and a side-opening) is directed into the pleural cavity [Figure 2]a. The tip is then manipulated with a grasper through a port to reposition the end before insufflating the bulb [Figure 2]b. It must be noted that an assistant must hold the mucus trap barrel and the lid over it tightly [Figure 1]c when the insufflator is squeezed; otherwise, the sudden high pressure generated within the trap can open the lid explosively with spillage of talc. During talc poudrage, if the spraying seems ineffective, temporary halting of carbon dioxide (CO2) insufflation (if being used to maintain capnothorax) can be tried, which will ensure increasing the pressure difference between the mucus sucker and the pleural cavity with resultant improvement in talc dispersion.
|Figure 2: Talc pleurodesis using the novel contraption. (a) The tube of the mucus extractor is directed into the pleural cavity. (b and c) The tip is then manipulated with a grasper through a port to reposition the end before insufflating the bulb. (d) Uniform dispersion of the sterile talc powder in a controlled way|
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This technique was used in a 15-year-old female with a recurrent spontaneous pneumothorax who had previously undergone failed pleurodesis with povidone-iodine twice. Two grams of sterile talc was instilled using the thoracoscopic poudrage technique with this improvised technique. The insufflator generated peak pressures of up to 95 cmH2O (checked with a manometer), which helped in the uniform dispersion of the sterile talc powder in a controlled way [Figure 2]b, [Figure 2]c, [Figure 2]d. Postoperatively, pneumothorax was resolved, and the patient was discharged on the 6th postoperative day. The patient is on regular follow-up and is asymptomatic with no recurrence of pneumothorax after 12 months.
A similar technique has been described by attaching one end of the mucus extractor to a laparoscopic CO2 insufflator. However, this requires insufflator equipment used for laparoscopy. It is important to note that because the pressure exerted manually through the insufflation bulb is under the operator's direct control, the poudrage is done in a more controlled way than when a laparoscopy insufflator is used. The tip of the mucus sucker can also be maneuvered into crevices and recesses as desired with a separate grasping instrument, and then talc dispersal can be carried out. On the other hand, when the CO2 insufflator is used for talc dispersion, this kind of fine-tuning and control is difficult to achieve. Our described modification allows the operator to disperse the talc, pause, re-evaluate, and then reposition the tip of the mucus trap for re-dispersal [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. This helps in the uniform spread of talc to the entire pleural surface effectively.
Our novel technique of thoracoscopic talc poudrage using a mucus extractor connected to a manual insufflation device is thus a cost-effective alternative to the commercial aerosol form of talc poudrage kit. This contraption can have vast implications in a resource-challenged setup.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Stefani A, Natali P, Casali C, Morandi U. Talc poudrage versus talc slurry in the treatment of malignant pleural effusion. A prospective comparative study. Eur J Cardiothorac Surg 2006;30:827-32.
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[Figure 1], [Figure 2]